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PR 05ya•55z <br /> SAN.,JOAQUIN Environmental Health Department <br /> 1A'r0 —COUNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> j 1 . To be completed by APPLICANT <br /> Business Name CNG IT S Plate# <br /> Owner/Operator Name C� <br /> Business Mailin Address 2 h� Id <br /> C ity tate�Zip �2�b Bus. P 12 313$� Alt. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a dd,penalties. �f <br /> Signature ✓ Date 10 v <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Nam <br /> Address 10 Stj Bus. Phone 2 <br /> CitZip 2.0 OwnerlOperator V(A o f v <br /> Che k all appropriate services provided: <br /> wastewater disposal 12-13-compartment sink CY16ectdcal hook-ups <br /> 00� Solid waste disposal Food preparation B"Toilet and handwashing <br /> U1 of&Cold water for cleaning ❑ St a refrigerated food Crt'Potable water <br /> Store dry food/supplies OveFY <br /> might parking Ve/�hicle wash <br /> 1, hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to Iy with the conditions of this agreement, o if this agreement is modified or cancelled, the <br /> commissary ow <br /> S 40tify HD' ediately. <br /> Signature ( Date <br /> -OL <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa(!Wn' Co. ; <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD ff the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 ; T 209 468-3420 ; F 209 464-0138 1 mvw.sjgov.org/ehd <br />